Sexual Discomfort: Dealing with Dysfunction in MS and Other Neurological Conditions

To be sure, a communication gap exists between physicians and patients on the topic of sex. A 2008 survey conducted by Ipsos Public Affairs and sponsored by Eli Lilly, makers of Cialis, found a lack of communication between patients with erectile dysfunction (ED) and their physicians. Almost 40 percent of the roughly 3,000 men with ED that the researchers interviewed had not talked to their doctor about their problem. This goes hand-in-hand with a Journal of American Medical Association study that reported that 75 percent of patients think their physicians would dismiss their sexual health concerns.

While healthy sexual function depends on the delicate interplay of nerves, muscles, and hormones, dysfunction is not generally considered a neurologic concern. This may be especially surprising, given that sexual dysfunction can be a comorbidity or a side effect of therapy associated with numerous neurological diseases, including Parkinson's disease, multiple sclerosis, stroke, and more.

Recognizing that dialogue about sexual dysfunction (SD) may be stifled and that SD is a common though perhaps under-recognized comorbidity of neurological diseases, neurologists should make an effort to address the problem with patients, as many effective interventions exist for various SD concerns. Following is a look at SD and the neurologist with a special emphasis on MS. Note that the patient management tips and interventions would apply to just about any patient presenting to the neurologist with concerns about SD.

START A DIALOGUE
When it comes to SD associated and the neurology patient, John Morley, MD, Professor of Internal Medicine and Interim Division Director of Endocrinology at St. Louis University, contends that it's the responsibility of all physicians to ask patients if they are experiencing sexual problems. He recognizes that there may be discomfort on the part of the neurologist but says that doctors must move beyond it. To ease into the sexual questioning, he suggests asking about sexual function when bringing up bladder dysfunction. "It doesn't matter what age the person is," he says. "But for the vast majority of physicians its very hard because they were never asked to and never trained to do it. Part of it, I think, is just forgetting. It's not one of those questions people made you ask when you were in medical school."

Another way to ask this sometimes tricky question is to include it on patient-completed questionnaires. The intake form could include symptoms of sexual dysfunction among possible symptoms and side effects the patient may be experiencing. "If the patient checks it, you as the doctor are going to be much more comfortable because you know it's something worrying the patient and they want to talk about it."

There may be some sense that a patient would almost certainly feel comfortable broaching the topic of sexual dysfunction with their neurologist because he or she already discusses so many personal or private matters, including relationship concerns, financial worries, employment challenges, and even end-of-life care strategies, with the doctor. But this is not necessarily so, says Dr. Morley. Even among those with Multiple Sclerosis, some patients feel doctors are the ones who need to lead patients in the questioning. Once the door is open, they'll usually readily continue the discussion. "These are people who bare their souls before us, to them it's not a problem. That's what we exist for," he says.

In one study of MS patients, at least one symptom of sexual dysfunction was present in about 84 percent of men and 85 percent of women.¹ This compares to estimates of SD occurring in about one-third of men and 40 percent of women in the general population. However, diagnostic criteria do not specify any disease-associated SD syndromes. Both the Diagnostic and Statistical Manual of Mental Disorders-IV and International Classification of Diseases-10 focus on the phenomenology of the sexual response without any specificity to diseases.² This can make an uphill battle all the more difficult, when neurologists don't have a widely-known "You Are Here" marker to show patients on their map.

CONSIDERATIONS FOR MALE PATIENTS
Few patients will want simply to talk about SD. They'll want the reassurance of knowing that others have similar problems and that treatments may help improve their problems. Among patients with MS, the most common SD problems for men are erectile dysfunction and ejaculation issues.³ But men with MS may experience any of the following:⁴

• Loss of libido
• Reduced sensitivity in the penis
• Difficulty having orgasm
• Fatigue
• Difficulty with movements/positions involved in sex

A study³ also reported that "a significant positive relationship was found between sexual dysfunction and lower-limb and bladder disability." There is no association between the duration of MS or patient age and SD in men or women with MS, according to results of this study.

In one study's1 cohort of men with MS, negative correlations were observed for all domains of quality of life, but they were statistically significant for physical health, physical role limitations, social function, health distress, sexual function, and sexual function satisfaction (P<0.01), using a Szasz sexual function scale and MSQoL-54 (Serbian version). The authors found that the presence of all the analyzed types of sexual problems statistically significantly lowered scores on the sexual function and the sexual function satisfaction subscales in both men and women (P<0.01).

The good news is that many problems with sexual dysfunction that may arise in MS or other neurologic conditions are treatable, and a wide range of products are available.

Oral medications: ED medications help achieve and maintain erections and are effective in about 50 percent of males with MS.⁴ For therapy to be successful, males must feel aroused, which may require manual stimulation and other forms of foreplay.

Injectable medications: Injected using a small gauge needle at the base of the penis into the corpora cavernosa just before sexual activity, these agents take about five to 10 minutes to activate—even with no stimulation. Results of a single treatment can last anywhere from one to two hours.

Injection therapy can be administered as monotherapy with prostaglandin E-1 or a multiagent mixture such as a trimixture of phentolamine, papaverine, and prostaglandin E1; a quadmixture of phentolamine, papaverine, prostaglandin E1 and atropine; or a bimixture of phentolamine and papaverine.5 Prostaglandin E1 can be compounded generically or is also dispensed as injectable alprostadil, either as Caverject Impulse or Edex.⁵

Penile treatments: A few treatments are available including two and three-piece inflatable implants as well as semi-rigid malleable rods. These are considered after other treatments have failed and carry a sticker price of $10,000-15,000, though many insurance providers, Medicare included, cover some of the cost.

Muscle relaxants and pain medication: Various medications can help spasms and pain that often interfere with sex.

An interesting note is that sildenafil (Viagra, Pfizer) may also have a beneficial therapeutic effect in the treatment of stroke, subarachnoid hemorrhage, dementia, learning, and neurodegenerative disorders by enhancing angiogenesis and neurogenesis.⁶ It also favorably influences the nitric oxide-cyclic guanosine monophosphate pathways, which are involved in the pathogenesis of a number of neurological diseases.

Although sildenafil shows some promise as a therapeutic agent in selected neurological disorders, well-designed clinical trials are needed before the agent can be recommended for use in any neurological disorder.

Bottom line: Regardless of the primary diagnosis, Dr. Morley sums up, "For neurologists, they should be paying attention to premature ejaculation and failure to ejaculate because they are commonly associated with neurologic disorders," he says.

CONSIDERATIONS FOR FEMALE PATIENTS
Vaginal dryness and subsequent painful intercourse are two of the major sexual function problems for women, Dr. Morley says. Lack of orgasm and sexual enthusiasm are treatable and not uncommon within the neurological realm, he adds. "These are things that should be asked about. At the minimum the question should be, 'Do you have any sexual problems you want to talk about?'," he says.

To deal with these problems, patients can explore several options:

Vaginal estrogen therapy: Treating vaginal dryness is typically more effective with topical estrogen rather than oral estrogen. Estrogen applied to the vagina can still result in estrogen reaching bloodstream, but the amount is minimal.⁷ Vaginal estrogen also doesn't decrease testosterone levels the same way oral estrogen can.

Vaginal estrogen therapy comes in several forms:

• Vaginal estrogen cream (Estrace, Premarin, others). Patients insert this cream directly into the vagina with an applicator, usually at bedtime. This is usually a daily regimen for the first few weeks and then application two or three times a week thereafter is adequate.
• Vaginal estrogen ring (Estring). A soft, flexible ring is inserted into the upper part of the vagina by patients or their physician. The ring releases a consistent dose of estrogen while in place and should be changed about every three months.
• Vaginal estrogen tablet (Vagifem). Patients use a disposable applicator to place a vaginal estrogen tablet in the vagina. Usually applied daily for the first two weeks, application twice a week thereafter is an appropriate regimen.

Timing of other medications: Stachowiak writes that certain medications can impair sexual functioning and recommends taking sexual activity into consideration with timing of medications, if problematic.⁸ See Table 1.

Make a map of the body: Because MS affects the processing of nerve signals, things that formerly stimulated someone with MS may no longer do so. Patients can make a sensory "body map," in which they systematically touch themselves and see what parts respond, and how. An open line of communication with their partner is paramount and this information should be shared.⁹

Kegel exercises: Also known as "pelvic floor exercises," these might be best explained to patients as tightening and releasing the muscle that controls the stream of urine.

Bottom Line: Regardless of gender, a wealth of tips will be highly individualized to the patients and the dynamic of the relationship with their partner. While medications and therapies are important, issues like communication and reassurance need to be in place in any relationship.

ADDRESS THE CONCERN
Neurologists are used to assessing and monitoring patients' function over time, including measurement of activities of daily living. Unfortunately, sexual activity is often overlooked. In order to effectively manage the whole person, neurologists must open the door to discussion of sexual dysfunction. Obviously if the neurologist truly does not feel equipped to handle the patient's complaints, he or she can consider referring the patient to a urologist, OB/Gyn or other specialist, as indicated.

Dr. Morley says the expertise of urologists, endocrinologists, gynecologists, and geriatricians can come into play, but he cautions against directing patients to a provider without the proper sexual health background. "Don't assume because someone is in one of these areas that they're more comfortable than the neurologist. You're looking for someone in the area who's got a reputation in your community for effectively handling sexual dysfunction."

Dr. Morley says web sites like webmd.com and thedoctorwillseeyounow.com (where Dr. Morley assists with questions) are valuable tools for patients seeking information. "Starting off, I would encourage the patient to see a doctor who knows something and then go and read up about something and not the other way around." This can offset some of the problems associated with inferior web sources. "Once patients have gone to the web and then come to me with such bizarre ideas that it takes me longer to reeducate them than to fix the problem," he notes.

1. Tepavcevic DK. The impact of sexual dysfunction on the quality of life measured by MSQoL-54 in patients with multiple sclerosis. Mult Scler. 2008 Sep;14(8):1131-6.
2. Bitzer J. Sexual counseling for women in the context of physical diseases: a teaching model for physicians. J Sex Med. 2007 Jan;4(1):29-37.
3. Fraser C. Correlates of sexual dysfunction in men and women with multiple sclerosis. J Neurosci Nurs. 2008 Oct;40(5):312-7.
4. Stachowiak, J. My husband has MS and doesn't like sex anymore. Why? http://ms.about.com/od/forfriendsandfamily/f/husband_ms_sex.htm
5. Albaugh, J. Intracavernosol Injection Algorithm: Penile Injectable Medications for ED. http://www.medscape.com/viewarticle/551563_3
6. Farooq MU. Role of sildenafil in neurological disorders. Clin Neuropharmacol. 2008 Nov-Dec;31(6):353-62.
7. Mayo Clinic. Vaginal dryness. http://www.mayoclinic.com/health/vaginal-dryness/DS00550/DSECTION=treatments-and-drugs
8. Stachowiak, J. Top 10 Sex Tips for Women with Multiple Sclerosis. http://ms.about.com/od/ livingwellwithms/a/sex_tips_women.htm
9. Kalb RC. Multiple Sclerosis. The Questions You HaveÑThe Answers You Need. 3rd ed. New York: Demos Medical Publishing, Inc; 2004.